Investor Interest Form

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email*

Business Profession*

Professional Title*

Referred By (if applicable)

Licensed with FINRA or SEC*

I am a Registered Representative working for a Broker Dealer
I am a Registered Investment Advisor (RIA)

Please select all that apply

Firm*

Certification of sophisticated investor status*

I have such knowledge and experience in financial, investment and business matters that I am capable of evaluating the merits and risks of any investment of any investment
I am using a financial adviser, planner, consultant, or some other adviser who has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of any investment

Please select which is true for you

Certification of accredited investor status*

a) My individual net worth, along with the net worth of my spouse exceeds $1,000,000, excluding the value of my personal residence and excluding from my liabilities the mortgages of my primary residence, provided the mortgages to not exceed the value of my primary residence

(b) My individual income was in excess of $200,000 in each of the past two years (excluding my spouse’s income) and I expect to have income (excluding my spouse’s income) in excess of that amount in the current year or my individual income for each such years together with my spouse’s is in excess of $300,000 each

Yes, (a) is true
Yes, both (a) and (b) are true

Signature confirmation*

I confirm, by typing my name above and electronically submitting this form, that the information supplied herein is current and accurate. I agree to sign a printed copy if asked to do so by recipient.

For any questions or concerns, please contact info@overtoncap.com

Securities offered through Independent Investment Bankers Corp, a broker-dealer, Member FINRA, SIPC. Overton Capital Corp. is an independent entity from Independent Investment Bankers Corp. FINRABrokerCheck.